Healthcare Provider Details

I. General information

NPI: 1649209594
Provider Name (Legal Business Name): BASIL P SPYROPOULOS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

926 S 8TH ST
MANITOWOC WI
54220-4535
US

IV. Provider business mailing address

PO BOX 764
LAKE GENEVA WI
53147-0764
US

V. Phone/Fax

Practice location:
  • Phone: 920-683-4230
  • Fax:
Mailing address:
  • Phone: 262-248-2640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number47302
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier47302
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: